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HomeMy WebLinkAboutBuilding Permit 12. 1021 r d M ra iaatiargr CITY OF PRIOR LAKE �_ pipLa tta?n o ax ltsprr Li > ❑ Final Permitted ❑ Condit C.O. Expires T his Certificate issued pursuant to the requirements of Section 110 of the ❑ Re sidential / ❑ Inte rnational Building Code certifying that at the time of issuance this structure was in compliance with the various %,,,,,,:?/: - ordinances of the City of Prior Lake regulating building construction or use. For the following: Use Classification SING' F FAMILY Bldg. Perm N o. 1 2 - 1 Q' ? 1 � . VN,I PHD Occupancy Type �_ � Type Construct nn Zoning District Legal Description 1 1 48 R 1 r .1 F F F F R S W A T E R F R O T ' r 14361 PARKSIDE COURT Owner of Building Site Address Contractor's Name & Address M A T T A A Y I ' I WI F S ROBERT D city Planner ' ilding Official Date: //77/ Date: POST IN CONSPICUOUS PLACE � . ,� �{ (r`i C � S , �H r �. �t � .: r '� "p �'� k �.: )��� �3 ❑\ p r � Y ^. �v ��r ";i i %;� � tiy s � �� .:I. i > l " �: i >. `4 4 l : 1, - _ � . - - _ i ^^ k zk � . K <7 0 § � z z K t� o w w co 0 k IV o N SQ�u • z Al OOOC § § ft , 2 § _ o v . , 2 a w d 0. o w & z S / % 000( 4 ' 1 § \ 0 4. § 0 w z ■xxzX 0 g a § m ■■� u) 0 a s=w s= § =u a 2 2 / z | �� u ® , ■ Q. u § § § § 2 000000 1 o 8 o■ w ; a a 2 X in ` TI ce 2 d ■ \ / § I- k ° U. « & $ % 0 z k / J �g u) ® 2o2� 05 « 0 0 % Bus 2 _ �§� § L.: -I % i l k § 0 J 2 u i 0 0 S 2 k Q 0z « 0 a 000000 0 0 0 E. 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W Z O z V ,„ z W ZLc== 0 ra .6 V V g co 4 m !L'Zm V d a I ! 1 V ,, ' W Z V a ❑❑❑ ❑ II W W W X o t a a LL i Y UJ W • s r 0 ~ J 50 0 0 a 0 w ce \., f Z -0 0p00 a 1-- v y F' �� °�° r FE 1: 4 41 ar." co i z o z ~ z W � ■ d 11J -I IQ III, ix O G' W = O W i H 0 0 L Z G 2 u.u.u, O �`�i O a' Q O Q 0 a 0000❑❑ U 0 v V IN) ❑ X.❑ c Ai rX /O\ CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd U N O � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE i 30. AND UTILITY CONNECTION PERMIT �NAIES File L1 ain White PERI�IIT NO. Z. City iz / 02 / 3. Yellow Applicant (Please type or print and sign at bottom) ADDRESS 14361 PP02 - C ZONING (office use) PUD LEGAL DESCRIPTION (office use only) LOT I- k EBLOCK t ADDITION ( 4 t =Ef2 —s KJa PID 254"1 (6o ' 48)0 OWNER (Name) 1'1 A T i A- M `' -I-4 0 t"t F--.S (Phone) (Address) 1221.1 IN A S 1-1- t h1 t, cl *--1 A vie S STS 2p t t =0 t t..t 4k N N SS 43 9 BUILDER (Company Name) MS i 4 t"i ES (Phone) (Contact Name) S v a ' 8 1/4. 1 (Phone) (Address) 1'2 l 1••. Pc 5 4 11-4 C, is, t./E.. 5 STS w t > -O t u A t•-t t�.1 SSL4 39 TYPE OF WORK yg New Construction Eg.Deck ['Porch ❑Re- Roofing ❑Re- Siding ❑Lower Level Finish ❑ Fireplace ['Addition ['Alteration ['Utility Connection CODE: R.R.C. ❑I.B.C. ❑ Misc: Type of Construction: I II III IV V A B Occupancy Group: A B E F HI MR S U PROJECT COST /VALUE $ 1 X1 1 000 , Division: 1 2 3 4 5 (excluding land) I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify that I am the owner or authorized agent for the above - mentioned property and that all construction will conform to all existing state and local laws and will proceed in accordance with submitted plans. I am aware that the building official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may enter upon the property to perform needed inspections. g (S..,...___, ` � c,,— ,— Re_- 2-cz. 3 532>b a - 29 - 12 Signature Contractor's License No. Date Permit Valuation (5 ow, - Park Support Fee # $ Permit Fee $ SAC # $ Plan Check Fee $ 819-193 Water Meter Size 45' 1" $ it So ` State Surcharge $ 1 S I _ Pressure Reducer $ Penalty $ Sewer /Water Connection Fee # $ 1 5- Q 0- Plumbing Permit Fee $ (5.41.(7° Water Tower Fee # $ ( OOD - Mechanical Permit Fee $ l S -co Builder's Deposit $ CS O d - Sewer & Water Permit Fee $ Other Gas Fireplace _ ' ermit Fee $ S TOTAL D $ re 4'7 7t �� This App ' , :o Bec Building Permit en A roved Paid �- - _ grceipt No.(, ' ' " / Date //..r, /Z I \ 4ii0 /- (7 (t \ Buildin • Offici . -- Dat: * This is to ce '' at the request , e bove app cation and accompanying docum: is is n accordance with the City Zoning Ordinance and may proceed as requested. This document t n.. ■ when signe. e C P .. : co "s • tes a temporary Certificate of Zoning comp . ce nd allows construction to commence. Before occupancy, a Certificate of Occupancy must be issued. f Gir i . Plannr, - - fate Special Conditions, if any 4 h.. notice for all inspections (952) 447 -9850, fax (952) 447 -4245 6 Dakota Street S.E., Prior Lake, Minnesota 55372 04 PRIOR ti U tv White - Building Canary - Engineering &NES°'. Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT /41 APPLICATION RECEIVED S 30 • i ' The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: /43& /- / i°/q11-1,S/0&• - t . Accepted ✓ Accepted With Corrections Denied Reviewed B : / �J _' Date: 4/r_._ Y Comment • Cow 61-) s t-w- � /,- #1. - ,0 c-- 4. • . At ared N . "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." U t�tf White - Building Canary - Engineering ` INNESOS Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT /7777//14 APPLICATION RECEIVED .) 3 O • t �''"- The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: Accepted ✓ Accepted With Corrections Denied Reviewed By: Date: r 7 (_.- Comments: "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." o White - Building '-4NNESOtP Canary - Engineering Pink - Planning BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST NAME OF APPLICANT / 77/ APPLICATION RECEIVED S 30 • / Z-'"' The Building, Engineering, and Planning Departments have reviewed the building permit application for construction activity which is proposed at: /j.3 2 /-- / 3 7 9/i /c c--S /1) , Accepted ,( Accepted With Corrections Denied • Reviewed By: MIS Date: 9 Comments: See Reverse Side for Additional Informatinnl See Attachments: 1) Grading Plan, 2) Erosion Control Standards "The issuance or granting of a permit or approval of plans, specifications and computations shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of this code or of any other ordinance of the jurisdiction. Permits presuming to give authority to violate or cancel the provisions of this code or other ordinances of the jurisdiction shall not be valid." ADDITIONAL COMMENTS FOR BUILDING PERMIT APPLICATIONS • Surface storm water drainage flowing to the perimeter of this lot to and from adjoining properties must be conveyed to the roadway and /or to the rear of the lot in drainage swales within the drainage • easement. • • All- bare soil areas must be protected from eroding into neighboring properties through the properly installed and maintained silt fence or bales. . . • • The'silt fence required by the - erosion control plan must be installed prior to any earthwork being started. • • The builder is responsible for maintaining the erosion control measures until the turf is established. • _. The rock construction entrance must be installed at the time of t hbackfilling of the foundation. • . • • • • • • • • • • • • • 6: \ Admin Wept info \ADDITIONAL COMMENTS FOR BUILDING PERMIT APPLICATIONS.doc CITY OF PRIOR LAKE 13C11.,DING PER.7k1IT, r)*:. Red TEMPORARY CERTIFICATE OF ZONING COM PLIANCE AND L I 1 L1TY CONNECTION PER NI IT "N.,: ‘: ,„%,•-,, :, -----__--": PERMIT NO fyle_xce , Pr prrst and .___,I,p At 1 — , ADDRESS ZONING I.EG AL DESCRIPTION t. use BLOCK ADDITION PID OWNER r'\\ ', ';•-•k\t‘ 0 C„sf-A.E:,..' ':--,,,, _ (Phone) ''''''' ' 7 f . -- '?'"•.-..,._____________' ) (Ad i r e'S 5- . 7 2.,;:; i ‘,.,A.... P t iNt..:,A C•k f\\ Li '*".',, . HUMBER C._.,... Cy Narattli (..; Li .,"/:::. ,-. '‘---,.., *i....i:. ; (Phone) c, ame) 1 t- fs-4,1)171----' (Phone) :.•. L 1 t c:7 :C t,„.,A, )■„,, 7:: . IC c t \ ( L CF....1.2_ ..--12 1 Q.: ' ,) _. ii C.:: H I, 1_,. TYPE OF WORK gtiew Construi,, 017.,..-, K. 7: 7. . DR.' .4 : .: .. ,,2 .- ,...: ( LAJdip.or 0 Vz,-7..i.....; El. ::.',, .,.:, ccmt: p.R.c. ELBA:. .M:, 1 's,, 4 ..).P)..( 1pe of Construction: 1 11 111 1V V A 13 --. .. . Occurincy Group: ABE 1 11 1 NIC,1.1-,SU PROJEC T COST!VA1 . 1..T S - ' — ' Divisin: 1 2 (i; 4 5 (c‘citsding land) -1 ..... - . ---- -. Sigr..11-.1:e . — P::;.: 5 .:-,- ,': --..-. • :.;.., '',,,', .-7.:--- ' ........., ,.. 5 ., , A:, : ::- Chc.:,.: et.- 5 - \• R''': 7.1+.:! ',..,: ^' , ,;,' . 5 , Pre F,,'‘: ---- — ------ i :: 5 5 — ----- .. ,:.- '..-... 5 Bill.". ' 1.:' - 5. ---- N. Fe... i S .e., 5 1 r-r:It F,...z. ; 5 - TOTAL DUE ... 4 PA lb WP- .....:,_ ArAiwo k _ . ______ _ ainimiy TN ' t , p ir ., - *tour Podding Permit ‘ ro wh ,,i i 4iF Paid i Receipt 1 !" - 1 oat, rfiv Aii. N f *// Burr: c Offici31 - -- — _ the r..1 :r - 7; r: -; ':, — 7 ':', ;•7 -: . : ,- in 3,1.-..,,4,17.:::: -.11, 9-,.. :_,;n :',.';',', ,. ■,,.- M r'7,''' a' -...t° .....f. :7 ,:, .•.‘ire c.74,7111. eN: C7 Pt e zonFro ..., , ,,, ,;.,,,-, ; ,, -,, .„2,--, ; , , ---: „, --,,! :..: ::;,. :. .,,- ---, ---- ‘ -::.----,-.-. '..." . : 1 ( ,!,.",:.<:r'.7...- r:'.." 7' PISM:114.D'IWor 1 ----- ....- -.. 24 bola-11,41-7, f.:r all , n8pettions (.9.52) f 011 44-4245 'Mari Ihtc,13 'it ''; F., Prim 1 tke, Mitmeota 55372 From:Genz -Ryan 952 767 1900 10/17/2012 15:38 #657 P.002 /0. PO F y Rio Date Recd Atil y CITY OF PRIOR LAKE PLUMBING PERMIT 4,„,...00. t' a'"` Fe [PERMIT NO.' Z z. cads car 3 YNkw Applicant (i'ieaae type or print and din at bottom) ADDRESS w ZONING <oe oxe) / 1A., c 0_\ f ?(XA_A_S\ L ‘ (AC_ 1 \W LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID OWNER (Name) (Phone) -- (Address) APPLICANT (Name) GENZ -RYAN (Phone) 952 -767 - (Address) 2200 IGHWAY 13 W , BURNSVILLE, MN 55337 (Address) �� (City) (Zip Code) (Contact Person) V T c i S (Phone) 9 52 - 7 6 7 - 1 he q APPLICANT SIGNATURE AA DATE 101 171 It ' APPLICANT PLEASE COMPLETE BELOW Quantity Type of Fixture Quantity _ Type of Fixture Z . Tub with or without shower Rough -ins Dishwasher rs Water Heater — Floor Drain Water Softener Lavatory (Bathroom Sink) ` Stand Pipe (Washing Machine) Laundry Tray (1 or 2 compartment sink Sewage Ejector _ Z.. Shower Stall _ Backflow Assembly ( Sinks Backflow Assembly Test ,.--- Bar Sink Lawn Sprinkler L ` Water Closet (Toilet) Other FEE SCHEDULE ,�,: , , F Industrial, Commercial & Multi-family 114 of job costwitb a 249.50 minimum 1;iy.�itlxi iii , +je>vag. i j�-Tuitily��i.it49 5d'+ 1; Residential, Additions & Alterations 249.50 The Minnesota Statutes a 32613.145 That S Building Permit "SURCHARGE" effective has been changed for one y PLUMBING PERMIT FEE S k "t 1. 1 0 0 • year July 1, 20114 until June 30, 2011. STATE SURCHARGE $ .50 'fhe minimum surcharge fora "fixed be" permit TOTAL PERMIT FEE S %PIO , Q b 1s K,_i. beginning July 1, MO AID MIL Thds Application Becomes Your Building Permit When Approved Paid BURDING PERMIT Date By Banding Official Dste _ - _ 24 hour notice for all inspections (952) 4474850, fix (952) 447 - 4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 `Z` iZI' P Rio , CITY OF PRIOR LAKE Date Ree'd °t HEATLNG /AIR CONDITIONING/FIREPLACE PER r.37. " j try 4i1 50 'Cl' !. Pink Fiie PERMIT NO. 2. Y ello w Applicant City PERMIT 1� 3. Y IIo 2 • 1 (Please type or print and sign at bottom ADDRESS ZONING (office use) /q3 (21 P.,64,-4, 6r-cS illa LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PM OWN N (Name) ER /� (Phone) .'Z � -8-9t— 2-1°C) (Address) 72-0 �vG'LZ I �, 5 - z- n 'edit. - (/ y APPLICANT HEARTH & HoME TECHNOLOGIES, INC. (Name) dba FIRESIDE HEARTH & Lic. 8CO512060 . (Address) 2700 FAIRVIEW AVENUE N (Address) ROSEVILLE, MN 55113 (City) (Zip Code) • (Contact Person) ,, �� � [[%% 651.633.2561 hone) APPLICANT SIGNATURE Gr'4 0,MA✓ / cry DATE l ' 1 6 --- APPLICANT PLEASE COMPLETE BELOW ❑NEW CONSTRUCTION ❑ REPLACEMENT ❑ ALTERATIONS ' FURNACE MAKE AND MODEL FUEL FLUE SIZE RETURN OPENINGS INPUT OUTPUT TYPE OF SYSTEM HEATING OR POWER PLANT PLEASE NOTE: Air Conditioner ❑Warm Air Plants ❑ Steam Units and Fireplaces Cannot Encroach ❑Gravity ❑ Hot Water into Required Side Yard Setbacks. ❑ Mechanical ❑ Radiation Fireplaces with Box Additions or ❑Air Conditioning ❑ Special Devices ❑Vent. System 0 Other Devices Cantilevers to the Outside of Buildings Require a Building Permit. FIREPLACE MAKE AND MODEL /4- SL CSOTf -2f t Z4,v0r7 FEE SCHEDULE . Industrial, Commercial & Multi- Family 1% of job cost Residential, Gas Fireplace $49.50 • $49.50 minimum Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50 Residential, Heating Only (New Construction) $64.50 Residential, AC Only $49.50 . Estimated Cost $ / 0 X Building Permit It The Minnesota Statutes §326B.148 "SURCI 1ARGF;" has been changed For one HEATING PERMIT FEE $ year effective STATE SURCHARGE $ .50 July 1. 2010, until June 30, 2011. TOTAL PERMIT FEE $ The minimum surcharge for a "flied fee" permit (Office Use Only) is Ems, beginning July 1.2010 This Application Becomes Your Building Permit When Approved Paid Receipt No. Date MID WITH Bulldlne011ieial Date . _ BUILDING PERMIT ' 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 b ..). • s,•• .c, PR /0 Date Rec'd H CITY OF PRIOR LAKE /0 ,1 /. (2,-- SEWER AND WATER PERMIT c /2 ---/OZ-/ . Green Fite PERMIT NO. 2. Gold Applicant /2 . / O L� 3. Gold Applicant (Please type or print and sign at bottom) ADDRESS ZONING (office use) 1, L LB I 601 pC4AJ - P c__D • LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID (Name) OWNER 1 (Phone) (Address) (Address) (City) (Zip Code) APPLICANT ,/ � (Name) ' ` (Phone) (Address) -'31. 1.6 PAt-P (Address) (City) (Zip Code) (Contact Person) L1 1 lalir, ' A n+__ (phone) 6 (�' ^' 1 '? ' L i 0 APPLICANT SIGNATURE "AZ DATE /0 — /1 — /2-- APPLICANT PLEASE COMPLETE BELOW Size of water service inches. Location of any couplings from structure feet. Type of sewer pipe. ❑ ABC ❑ PVC ❑ Cast Iron Estimated length of sewer line feet. Clean out (if required) located at feet from structure. FEE SCHEDULE Residential sewer and water line connection $51.50 Industrial, Com'l & Multi - family 1% of job cost with a $51.50 minimum Sewer connection only $25.50 Water connection only $25.50 , Estimated Cost $ Building Permit # SEWER AND WATER PERMIT FEE $ ?'° P STATE SURCHARGE $ .50 E / TOTAL PERMIT FEE 0 U09 a (Office Use Only) This Application Becomes Your Building Permit When Approved Paid Receipt No. Date By Building Official Date 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 4646 Dakota Street S.E., Prior Lake, Minnesota 55372 From:Genz -Ryan 952 767 1900 10117/2012 15:37 #657 P.001/01e 1 • o rRrQ� CITY OF PRIOR LAKE Date Rec'd • A A ', L e HEATING /AIR CONDITIONING/FIREPLACE PERMIT 4 4Nt soar is PERMIT NO. I Z 0i 1 ). Yaw Applicant 6 ' (Please tie orprint and Ana at bottom) ADDRESS ZONING (office ace) 1 U SCOk ?01 as. \ \ UJ LEGAL DESCRIPTION (office use only) LOT BLOCK ADDITION PID OWNER (Name) (Phone) . (Address) . APPLICANT (Name) ` ' _' • i I t (Phone) • (Address) 41 • kk.A3 A (Aeklress x )Y i X 1 j 7 • • (Contact Person) 6 r� to Y l� (Phone) t (O I '-' 1 BIC) ' • APPLICANT SIGNATURE 14.. ii _ Al DATE , .APPLICANT PLEASE COMPLETE BELOW EW C TRU R r7 IV LACEMENT 0 ALTERATION�S11 (� • FURNACE MAKE AND MODEL OI t /� 0 1 t 2� 1?L) FUEL qk ela . FLUE SIZE RETURN P BNINGS ID INPUT 57 ( O( f OUTPUT 531 TYPE OF SYSTEM HEATING OR POWER PLANT . OW OWamr Air Pleats Steam Units and Fireplaces S PLEASE NOTE: Air Conditioner ari ty S et Water Cannot Encroach . •• soles1 ] Radiation into Required Side Yard Setbacks. ._;,= ' Conditioning [] Special Devices Fireplaces with Box Additions or !i ent. System l] Other Devices Cantilevers to the Outside of Buildings Require a Building Permit. FIREPLACE MAKE AND MODEL . FEE SCHEDULE Industrial, Commercial & Multi - Family 1 °% of job cost Residential, Gas Fireplace $4930 • 549.50 minimum R sl(1 (ia1, iatmg A '' C XI.? a r? t ism f `}= I t`:sikl9; sZ *� Residential, Additions & Alterations 549.50 Residend Heating Only (New Construction) 264.50 Residential. AC Only S49.50 Estimated Cost $ Building Permit # The Minnesota Statutes 1 32613.148 HEATING PERMIT FEE $ 1 Liii , "SURCHARGE" has been changed k►r one year effective STATE SURCHARGE $ .50 July 1, 2010. until June 30. 2014. TOTAL PERMIT PEE $ % • ©d The minimum meow for a' Nixed fee permit (Oflke Ilse Only) is Li, beginning July 1.2010 This Application Becomes Your Building Permit Wlien Approved Paid Receipt NAND WITH Data ByitUILDING PCRM1T Banding Official Date . 24 hour notice for all inspections (952)447-9850, fax (952) 447.4245 4646 Dakota Street SE., Prior Lake, Minnesota 55372 Contractor's Material & Test Certificate for Aboveground Piping PROCEDURE Upon completion of work, inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall be corrected and system left in service before contractor's personnel finally leave the job. A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. It Is understood the owner's representative's signature in no way prejudices any claim against contractor for faulty material, poor workmanship, or failure to comply with approving authority's requirements or local ordinances. PROPERTY NAME: JEFFERS POND DATE "- j' 13 PROPERTY ADDRESS: 14361 PARKSIDE COURT ACCEPTED BY APPROVING AUTHORITIES: CITY OF WOODBURY ADDRESS: PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS OYES ONO EQUIPMENT USED IS APPROVED YES ONO IF NO, EXPLAIN DEVIATIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS YES ❑NO TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: YES ONO 1. SYSTEM COMPONENTS INSTRUCTIONS OYES ONO 2. CARE AND MAINTENANCE INSTRUCTIONS RIVES ONO 3. NFPA 25 STYES ONO LOCATION ENTIRE BULDING YEAR OF TEMPERATURE MAKE MODEL MANUFACTURE SIZE QTY. RATING RELIABLE RES 49 2011 1/2 12 _— 165 - SPRINKLERS RELIABLE RES 44HSW 2011 1/2 15 155 RELIABLE F3QR 2011 1/2 1 155 PIPE AND Type of Pipe BLAZEMASTER FITTINGS Type of Fitting CPVC MAXIMUM TIME TO OPERATE ALARM DEVICE THROUGH TEST CONNECTION ALARM VALVE OR FLOW INDICATOR TYPE MAKE MODEL MIN SEC FLOW INDICATOR POTTER VSR - F S DRY VALVE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. DRY PIPE TIME TO TRIP TIME WATER ALARM OPERATING TEST THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED CONNNECTION• PRESSURE PRESSURE AIR PRESSURE TEST OUTLET' PROPERLY MIN SEC PSI PSI PSI MIN SEC YES NO W/O Q.O.D. WITH Q.O.D. IF NO, EXPLAIN LOCATION MAKE & SETTING STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE & FLOOR MODEL (FLOWING) PRESSURE REDUCING INLET (PSI) OUTLET (PSI) INLET (PSI) OUTLET (PSI) FLOW (GPM) VALVE TEST N/A OPERATION: CI PNEUMATIC ❑ELECTRIC ❑HYDRAULIC PIPING SUPERVISED OYES ONO DETACHING MEDIA SUPERVISED OYES ONO DOES VALVE OPERATE FROM THE MANUAL TRIP AND /OR REMOTE OYES ONO CONTROL STATIONS DELUGE & IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT IF NO, EXPLAIN PREACTION FOR TESTING VALVES OYES ONO N/A DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO MAKE MCNIFI RIIPFRVISIC)N I C)RR Al ARM OPFRATF VAI VF RFI FARE OPFRATF Fl FASF YES NO YES NO MIN SEC HYDROSTATIC: Hydrostatic test shall be made at not less than 200 psi (13.8 bars) for two hours of 50 psi (3.4 bars) above static pressure in excess of 150 psi (10.2 bars) for two hours. Differential dry-pipe valve clappers shall be left open during test to prevent damage. All Aboveground piping leakage shall be stopped. TEST DESCRIPTION PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop, which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours. Test pressure tanks at normal water level and air pressure and measure air pressure drop, which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours. ALL PIPING HYDROSTATICALLY TESTED AT PSI FOR _g_HRS IF NO, STATE REASON DRY PIPING PNEUMATICALLY TESTED OYES ® NO EQUIPMENT OPERATES PROPERLY YES ONO WA DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS? YES NO DRAIN READING OF GAGE LOCATE R WATER RESIDUAL PRESSURE WITIVALYE IN TEST CONNECTION TESTS TEST SUPPLY TEST CONNECTION PSI CONNECTION OPEN WIDE PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING. VERIFIED BY COPY OF THE U FORM NO. 85B OYES ONO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDERGROUND SPRINKLER PIPING YES ONO IF POWDER DRIVEN FASTENERS ARE USED IN EVES ONO IF NO, EXPLAIN CONCRETE, HAS REPRESENTATIVE SAMPLE TESTING BEEN SATISFACTORILY COMPLETED? BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED GASKETS 0 WELDED PIPING OYES NO IF VFR DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3? YES ONO WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3 YES ONO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISC ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED? OYES ONO CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL CUTOUTS (DISCS) ARE RETRIEVED? EVES ONO HYDRAULIC NAMEPLATE PROVIDED IF NO, EXPLAIN DATA OYES ONO NAMEPLATE REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: 3-- - 3 NA 0 SPRINKLER CONTRACTOR: FIRE SUPPRESSION SERVICES, LLC. TEST WITNESSED BY r" ` (SIGNED) TITLV 3 I DA VeCh. �/ FOR PRINKL CONTRACTO'. IGNED) /" TITLE DAT t )C (1Lj � - - (3 ADDITIONAL EXPLANA ION AND NOTES / .� ° rRZ0 Deposit p 1, 7N NEso City of Prior Lake A $1,500.00 Builders Deposit is included in the Building Permit fee. The Builders Deposit is issued as security to insure compliance for a Final Occupancy Permit. (It is not an escrow account.) All exterior items including but not limited to grading, sodding, landscaping, tree planting, driveways, siding and painting shall be completed 180 days after the date the building permit is issued. If the work is not complete within the 180 day time period, the City shall notify the applicant of the violation and the applicant shall have 10 days to comply or the $1,500.00 builders deposit will be forfeited and the applicant will be billed for clean up or corrective work to rectify the situation. A $500.00 Tree Deposit may also be required and will be refunded if specified trees are preserved for a period of one year. By signing I, the undersigned contractor, acknowledge that I am aware of the erosion control requirements of the City of Prior Lake as outlined in the Erosion Control Measures for Building Contractors handout. DATE: i SITE ADDRESS: 14/5‘..-k PN-12 -IBS` D F Co"' PERMIT #12 ./6 Z( REFUND TO BE MAILED TO: 1-1 in. S 120 l 1^/ASH-lN6moN P /G S Ski I'VE 20 t- 14 SS 43 9 PLEASE REMEMBER 1. KEEP STREETS CLEAN DURING CONSTRUCTION 2. KEEP EROSION CONTROL IN PLACE — -- P,. • ' S ' • uJ CLS _JR► 1'11 /Ul'ILU1,T1 !1 AIJTIIORIZ TO RELEASE SIGNATURE: ,/ / > 1 i ynda S. Alien, Building Services Acct. 801.2020 Date C:1Documents and Settingslsbare\Local SettingslTemporary Internet Files\ Content .Outlook \BD80X19A1BUILDERS DEPOSIT FORM.DOC P R I O R LAKE DEPARTMENT OF BUILDING AND IN • ist File INSPECTION R SITE ADDRESS „ j L / NATURE OF WORK N. , 4 0 .�� !,;JjAtiPz7j�; �4,�'[3 USE OF BUILDING a -0P PERMIT NO. /2. • /0 DATE ISSUED CONTRACTOR of LJd ' rre wI all' PHONE ; NOTE: PHIS IS NOT A PERM! FOR ANY OF THE INSPECTI • NS BELOW THE PERMIT IS BY SEPARATE DOCUMENT Install erosion control & maintain clean streets trail times. DATE FOOTING if447 1.7%."5-47/2____- I FOUNDATION (Prior to Backfill) �{t PCE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED L . Radon s ir3 u ,� , stem under concrete slab _ mIH INS SEWER / WATER / SEPTIC </ k ;is /c, / , FRAMING 12,N -ru • +` kic INSULATION / 3 - ELECTRICAL PLUMBING ue6 4J1 U>> , � I ' ) ' k� > %> ' /pr HEATING (if required) / FIREPLACE GAS LINE AIR TEST ladon piping COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED >Ystem. 0a Housewrap r' Fire Sprinkler( FINALS 0e 3/6/63 GRADING (Prior to Soddi ) BUILDING `(. C,, t:%. 1- 1 I ILXA I ( P,e / /7 /13 ELECTRICAL PLUMBING V/ ,.. HEATING \11, ';/14/13 DO NOT OCCUPY UNTIL ABOVE HAS BEEN SIGNED NOTICE This card must be posted near an electrical service cabinet prior to rough -in inspections and maintained until all inspections have been approved. On buildings and additions where no service cabinet is available, card shall be placed near main entrance. FOR ALL INSPECTIONS (952) 447 -9850